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Arslan S, Kocaoğlu İ, Yaralı O, Abuşoğlu Y, Kahveci H, Gökçe S, Kargı A, Aslan S, Yazar Ş, Polat KY. A successful liver transplantation in a patient with neonatal-onset carbamoyl phosphate synthetase-1 deficiency. J Pediatr Endocrinol Metab 2024; 0:jpem-2024-0240. [PMID: 39158197 DOI: 10.1515/jpem-2024-0240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 07/18/2024] [Indexed: 08/20/2024]
Abstract
OBJECTIVES Carbamoyl phosphate synthetase 1 (CPS-1) deficiency is a rare urea cycle disorder with an estimated prevalence of one in 150,000-200,000 live births. Patients often present with hyperammonemia shortly after protein feeding in the early days of life, and early-onset type is associated with high mortality rate. CASE PRESENTATION We present here a case of a newborn male with a history of two deceased siblings whose ammonium level exceeded 200 μmol/L on the first day after birth, and who was started on dextrose infusion and ammonia-scavenging therapy after oral feeding was discontinued. Peritoneal dialysis was initiated after the patient's ammonia level exceeded 500 μmol/L. At the age of five months, the patient underwent hemodialysis due to elevated ammonia levels accompanied by lethargy. The patient's ammonia levels were successfully brought under control, and the patient underwent a liver transplantation at the age of six month, donated by the father. CONCLUSIONS We present this case to emphasize the efficacy of liver transplantation from a parent carrying a CPS-1 deficiency. The authors believe that, with further support from future studies, the use of carglumic acid can improve the prognosis in the chronic management of CPS-1 deficiency.
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Affiliation(s)
- Sezai Arslan
- Department of Inherited Metabolic Diseases, Regional Training and Research Hospital, Erzurum, Türkiye
| | - İpek Kocaoğlu
- Department of Neonatology, Regional Training and Research Hospital, Erzurum, Türkiye
| | - Oğuzhan Yaralı
- Department of Medical Genetics, Erzurum Regional Training and Research Hospital, Erzurum, Türkiye
| | - Yasemin Abuşoğlu
- Department of Nutrition and Dietetics, Regional Training and Research Hospital, Erzurum, Türkiye
| | - Hasan Kahveci
- Department of Neonatology, Regional Training and Research Hospital, Erzurum, Türkiye
| | - Selim Gökçe
- Department of Pediatric Gastroenterology, Memorial Bahçelievler Hospital, İstanbul, Türkiye
| | - Ahmet Kargı
- Liver Transplantation Center, Memorial Atasehir/Bahçelievler Hospitals, Istanbul, Türkiye
| | - Serdar Aslan
- Liver Transplantation Center, Memorial Atasehir/Bahçelievler Hospitals, Istanbul, Türkiye
| | - Şerafettin Yazar
- Liver Transplantation Center, Memorial Atasehir/Bahçelievler Hospitals, Istanbul, Türkiye
| | - Kamil Yalçın Polat
- Liver Transplantation Center, Memorial Atasehir/Bahçelievler Hospitals, Istanbul, Türkiye
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Kakiuchi T, Nosho T, Oka M, Tashiro K. Hyperammonemia in a carbamoyl-phosphate synthetase 1 deficiency recipient after living-donor liver transplantation from a carrier donor: a case report. Front Med (Lausanne) 2024; 10:1327854. [PMID: 38235270 PMCID: PMC10792046 DOI: 10.3389/fmed.2023.1327854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/13/2023] [Indexed: 01/19/2024] Open
Abstract
Carbamoyl-phosphate synthetase 1 (CPS1) deficiency is an autosomal recessive congenital urea cycle disorder (UCD) characterized by hyperammonemia. The recipients of liver transplantation (LT) for UCD are often children, and the potential donors are often the parents. Hereditary congenital diseases involving UCD entail the possibility of both parents being genetically heterozygous. Herein, we describe the case of a 12-year-old girl with CPS1 deficiency receiving a liver transplant (soon after birth) from her father, who had a heterozygous CPS1 mutation. She was referred to our hospital with respiratory distress after contracting two infections (respiratory syncytial virus and human metapneumovirus) within a short period, both of which presented with hyperammonemia. Medication for hyperammonemia quickly lowered the ammonia levels. The hyperammonemia was thought to be caused by the heterozygous mutation in the donor liver; moreover, it is likely that the low enzyme activity in the patient's liver was increased due to the infections. This is the first study to report hyperammonemia in a CPS1 deficiency patient due to an infection after LT. Thus, patients with CPS1 deficiency should be aware of the development of hyperammonemia after LT.
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Affiliation(s)
- Toshihiko Kakiuchi
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Tetsuya Nosho
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Masafumi Oka
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Katsuya Tashiro
- Department of Pediatrics, Karatsu Red Cross Hospital, Karatsu, Japan
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Murali CN, Barber JR, McCarter R, Zhang A, Gallant N, Simpson K, Dorrani N, Wilkening GN, Hays RD, Lichter-Konecki U, Burrage LC, Nagamani SCS. Health-related quality of life in a systematically assessed cohort of children and adults with urea cycle disorders. Mol Genet Metab 2023; 140:107696. [PMID: 37690181 PMCID: PMC10866211 DOI: 10.1016/j.ymgme.2023.107696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/01/2023] [Accepted: 09/02/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Individuals with urea cycle disorders (UCDs) may develop recurrent hyperammonemia, episodic encephalopathy, and neurological sequelae which can impact Health-related Quality of Life (HRQoL). To date, there have been no systematic studies of HRQoL in people with UCDs. METHODS We reviewed HRQoL and clinical data for 190 children and 203 adults enrolled in a multicenter UCD natural history study. Physical and psychosocial HRQoL in people with UCDs were compared to HRQoL in healthy people and people with phenylketonuria (PKU) and diabetes mellitus. We assessed relationships between HRQoL, UCD diagnosis, and disease severity. Finally, we calculated sample sizes required to detect changes in these HRQoL measures. RESULTS Individuals with UCDs demonstrated worse physical and psychosocial HRQoL than their healthy peers and peers with PKU and diabetes. In children, HRQoL scores did not differ by diagnosis or severity. In adults, individuals with decreased severity had worse psychosocial HRQoL. Finally, we show that a large number of individuals would be required in clinical trials to detect differences in HRQoL in UCDs. CONCLUSION Individuals with UCDs have worse HRQoL compared to healthy individuals and those with PKU and diabetes. Future work should focus on the impact of liver transplantation and other clinical variables on HRQoL in UCDs.
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Affiliation(s)
- Chaya N Murali
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA
| | - John R Barber
- Children's National Health System, Washington, DC, USA
| | | | - Anqing Zhang
- Children's National Health System, Washington, DC, USA
| | - Natalie Gallant
- Department of Pediatrics, University of California Irvine, Irvine, CA, USA
| | - Kara Simpson
- Children's National Health System, Washington, DC, USA
| | - Naghmeh Dorrani
- Department of Human Genetics, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Ron D Hays
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Uta Lichter-Konecki
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lindsay C Burrage
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA.
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Jin X, Zeng X, Zhao D, Jiang N. Liver transplantation in rare late-onset ornithine transcarbamylase deficiency with central nervous system injury: A case report and review of the literature. Brain Behav 2022; 12:e2765. [PMID: 36128655 PMCID: PMC9575608 DOI: 10.1002/brb3.2765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/29/2022] [Accepted: 08/28/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Ornithine transcarbamylase deficiency (OTCD) is a genetic metabolic disease. Its clinical manifestations are mainly central nervous system dysfunction caused by high blood ammonia. Late-onset OTCD combined with central nervous system injury has a poor therapeutic response, which is one of the main factors affecting the prognosis and quality of life of patients. liver transplantation (LT) has gradually become a radical treatment for OTCD, which has achieved good results. However, there is no consensus on the timing of LT and problems of nervous system damage and repair. METHODS We report the development of late-onset OTCD with central nervous system injury in an 11-year-old child who received liver transplantation at our transplant center. His first symptoms were nonprojectile vomiting, followed by irritability and disturbance of consciousness, after which the disease progressed rapidly and finally resulted in a coma. After liver transplantation, the child's consciousness returned to normal, muscle strength of the limbs gradually recovered from grade 0 to grade 4, and muscle tone gradually recovered from grade 4 to grade 1, suggesting that the motor nerves had gradually recovered. However, the child is currently mentally retarded, and the language center has not yet fully recovered.At the same time, we made a literature review of OTCD. CONCLUSION For OTCD patients with central nervous system injury, liver transplantation can fundamentally solve the problem of ammonia metabolism in the liver and avoids further damage to the central nervous system caused by hyperammonemia. At the same time, children's nervous systems are in the developmental stage when neuroplasticity is greatest. If liver transplantation is performed as soon as possible, nerve repair is still possible.
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Affiliation(s)
- Xin Jin
- Division of Liver Surgery and Organ Transplantation Center, Shenzhen Third People's Hospital, Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen, China
| | - Xinchen Zeng
- Division of Liver Surgery and Organ Transplantation Center, Shenzhen Third People's Hospital, Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen, China
| | - Dong Zhao
- Division of Liver Surgery and Organ Transplantation Center, Shenzhen Third People's Hospital, Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen, China
| | - Nan Jiang
- Division of Liver Surgery and Organ Transplantation Center, Shenzhen Third People's Hospital, Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen, China
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Matsushita H, Fujiyoshi T, Yoshimaru K, Matsuura T, Mushimoto Y, Karashima Y, Yamaura K. Anesthesia management in living-donor liver transplantation in a patient with carbamoyl phosphate synthetase deficiency: a case report. JA Clin Rep 2022; 8:71. [PMID: 36070152 PMCID: PMC9452607 DOI: 10.1186/s40981-022-00558-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 11/29/2022] Open
Abstract
Background Carbamoyl phosphate synthetase deficiency (CPS1D) is a urea-cycle disorder (UCD). We report successful perioperative management of pediatric living donor liver transplantation (LDLT) in a CPS1D patient. Case presentation A 10-year-old female patient with CPS1D underwent LDLT. Proper administration of dextrose 50% and 60 kcal/kg/day with l-arginine and l-carnitine resulted in the avoidance of intraoperative hyperammonemia induced by hypercatabolism. Serum ammonia level transiently increased to 61 mmol/L in the anhepatic phase and decreased to 44 mmol/L after reperfusion. Conclusions We suggest anesthesia management with administration of dextrose to avoid hyperammonemia during LDLT in patients with CPS1D.
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Liu F, Bao LS, Liang RJ, Zhao XY, Li Z, Du ZF, Lv SG. Identification of rare variants causing urea cycle disorders: A clinical, genetic, and biophysical study. J Cell Mol Med 2021; 25:4099-4109. [PMID: 33611823 PMCID: PMC8051738 DOI: 10.1111/jcmm.16379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/01/2021] [Accepted: 02/04/2021] [Indexed: 12/23/2022] Open
Abstract
Urea cycle disorders (UCDs) are a group of rare metabolic conditions characterized by hyperammonemia and a broad spectrum of phenotypic severity. They are caused by the congenital deficiency in the eight biomolecules involved in urea cycle. In the present study, five cases of UCD were recruited and submitted to a series of clinical, biochemical, and genetic analysis with a combination of high throughput techniques. Moreover, in silico analysis was conducted on the identified missense genetic variants. Various clinical and biochemical indications (including profiles of amino acids and urinary orotic acids) of UCD were manifested by the five probands. Sequence analysis revealed nine diagnostic variants, including three novel ones, which caused Argininosuccinic aciduria (ASA) in one case, Carbamoyl phosphate synthetase 1deficiency (CPS1D) in two cases, Ornithine transcarbamylase deficiency (OTCD) in one case, and Citrin deficiency in 1case. Results of in silico biophysical analysis strongly suggested the pathogenicity of each the five missense variants and provided insight into their intramolecular impacts. In conclusion, this study expanded the genetic variation spectrum of UCD, gave solid evidence for counselling to the affected families, and should facilitate the functional study on the proteins in urea cycle.
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Affiliation(s)
- Fang Liu
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Li-Sha Bao
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Ru-Jia Liang
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Xiao-Ying Zhao
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Zhi Li
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Zhi-Fang Du
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
| | - Shao-Guang Lv
- Department of Pediatrics, NICU, Bethune International Peace Hospital (the 980th Hospital of the People's Liberation Army Joint Service Support Force), Shijiazhuang, China
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Sood V, Squires JE, Mazariegos GV, Vockley J, McKiernan PJ. Living Related Liver Transplantation for Metabolic Liver Diseases in Children. J Pediatr Gastroenterol Nutr 2021; 72:11-17. [PMID: 32969959 PMCID: PMC10657650 DOI: 10.1097/mpg.0000000000002952] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Metabolic liver diseases (MLDs) are a heterogeneous group of inherited conditions for which liver transplantation can provide definitive treatment. The limited availability of deceased donor organs means some who could benefit from transplant do not have this option. Living related liver transplant (LrLT) using relatives as donors has emerged as one solution to this problem. This technique is established worldwide, especially in Asian countries, with shorter waiting times and patient and graft survival rates equivalent to deceased donor liver transplantation. However, living donors are underutilized for MLDs in many western countries, possibly due to the fear of limited efficacy using heterozygous donors. We have reviewed the published literature and shown that the use of heterozygous donors for liver transplantation is safe for the majority of MLDs with excellent metabolic correction. The use of LrLT should be encouraged to complement deceased donor liver transplantation (DDLT) for treatment of MLDs.
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Affiliation(s)
- Vikrant Sood
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - George V. Mazariegos
- Division of Pediatric Transplantation, Hillman Center for Pediatric Transplantation
| | - Jerry Vockley
- Center for Rare Disease Therapy, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
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Xu J, Zhang A, Huang F. Biallelic mutations in carbamoyl phosphate synthetase 1 induced hyperammonemia in a neonate: A case report. Exp Ther Med 2020; 20:623-629. [PMID: 32537019 DOI: 10.3892/etm.2020.8717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 09/20/2019] [Indexed: 12/13/2022] Open
Abstract
The aim of the present report was to describe the clinical presentation, diagnosis, and treatment of a case of carbamoyl phosphate synthetase 1 (CPS1) deficiency in a neonate, specifically, a 3 day-old female who visited Hunan Provincial People's Hospital due to anorexia and lethargy for 1 day. Physical and laboratory examination, and MRI were undertaken. Whole exome sequencing (WES) was applied for molecular etiology identification. Sanger sequencing was utilized to validate the variants detected by WES. Structural modeling was conducted for pathogenic analysis. Clinical examination revealed increased intracranial pressure, hyperammonemia, reduced citrulline, and increased glutamic acid levels. WES identified compound heterozygosity of c.713G>C, p.Arg238Pro and c.2339G>A, p.Arg780His in CPS1 (NCBI reference sequence, NM_001875.4) as candidate pathogenic variants. Sanger sequencing validated these variants. Structural modeling further confirmed the pathogenesis of these mutations. In conclusion, CPS1 deficiency in neonates is a serious condition that may be misdiagnosed due to severe infection. WES can be a helpful tool in facilitating the diagnosis of this disease.
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Affiliation(s)
- Jun Xu
- Department of Neonatology, Children's Medical Center, Hunan Provincial People's Hospital and The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, P.R. China
| | - Aimin Zhang
- Department of Neonatology, Children's Medical Center, Hunan Provincial People's Hospital and The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, P.R. China
| | - Furong Huang
- Department of Neonatology, Children's Medical Center, Hunan Provincial People's Hospital and The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, P.R. China
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Khoja S, Nitzahn M, Hermann K, Truong B, Borzone R, Willis B, Rudd M, Palmer DJ, Ng P, Brunetti-Pierri N, Lipshutz GS. Conditional disruption of hepatic carbamoyl phosphate synthetase 1 in mice results in hyperammonemia without orotic aciduria and can be corrected by liver-directed gene therapy. Mol Genet Metab 2018; 124:243-253. [PMID: 29801986 PMCID: PMC6076338 DOI: 10.1016/j.ymgme.2018.04.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/02/2018] [Accepted: 04/02/2018] [Indexed: 02/06/2023]
Abstract
Carbamoyl phosphate synthetase 1 (CPS1) is a urea cycle enzyme that forms carbamoyl phosphate from bicarbonate, ammonia and ATP. Bi-allelic mutations of the CPS1 gene result in a urea cycle disorder presenting with hyperammonemia, often with reduced citrulline, and without orotic aciduria. CPS1 deficiency is particularly challenging to treat and lack of early recognition typically results in early neonatal death. Therapeutic interventions have limited efficacy and most patients develop long-term neurologic sequelae. Using transgenic techniques, we generated a conditional Cps1 knockout mouse. By loxP/Cre recombinase technology, deletion of the Cps1 locus was achieved in adult transgenic animals using a Cre recombinase-expressing adeno-associated viral vector. Within four weeks from vector injection, all animals developed hyperammonemia without orotic aciduria and died. Minimal CPS1 protein was detectable in livers. To investigate the efficacy of gene therapy for CPS deficiency following knock-down of hepatic endogenous CPS1 expression, we injected these mice with a helper-dependent adenoviral vector (HDAd) expressing the large murine CPS1 cDNA under control of the phosphoenolpyruvate carboxykinase promoter. Liver-directed HDAd-mediated gene therapy resulted in survival, normalization of plasma ammonia and glutamine, and 13% of normal Cps1 expression. A gender difference in survival suggests that female mice may require higher hepatic CPS1 expression. We conclude that this conditional murine model recapitulates the clinical and biochemical phenotype detected in human patients with CPS1 deficiency and will be useful to investigate ammonia-mediated neurotoxicity and for the development of cell- and gene-based therapeutic approaches.
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Affiliation(s)
- Suhail Khoja
- Departments of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
| | - Matt Nitzahn
- Departments of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Molecular Biology Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
| | - Kip Hermann
- Departments of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
| | - Brian Truong
- Departments of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
| | | | - Brandon Willis
- Mouse Biology Program (MBP), University of California, Davis, United States
| | - Mitchell Rudd
- Departments of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
| | - Donna J Palmer
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| | - Philip Ng
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| | - Nicola Brunetti-Pierri
- Telethon Institute of Genetics and Medicine, Naples, Italy; Department of Translational Medicine, Federico II University of Naples, Naples, Italy
| | - Gerald S Lipshutz
- Departments of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Molecular Biology Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Intellectual and Developmental Disabilities Research Center at UCLA, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States; Semel Institute for Neuroscience, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States.
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Kido J, Matsumoto S, Momosaki K, Sakamoto R, Mitsubuchi H, Endo F, Nakamura K. Liver transplantation may prevent neurodevelopmental deterioration in high-risk patients with urea cycle disorders. Pediatr Transplant 2017; 21. [PMID: 28608518 DOI: 10.1111/petr.12987] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2017] [Indexed: 12/13/2022]
Abstract
UCDs are among the most common inherited metabolic diseases in Japan. We investigated the clinical manifestations, treatment, and prognoses of 177 patients with UCDs who were evaluated and treated from January 1999 to March 2009 in Japan, using a questionnaire survey. Among these 177 patients, 42 (seven with carbamoyl phosphate synthetase 1 deficiency, 27 with ornithine transcarbamylase deficiency, seven with argininosuccinate synthetase deficiency, and one with arginase 1 deficiency) underwent living-donor LT. Although this study was retrospective and included limited neurodevelopmental information before and after LT, we evaluated whether LT could improve neurodevelopmental outcomes in patients with UCDs. The neurodevelopmental outcomes of patients with a MAC of <300 μmol/L at the time of onset were not significantly different between the LT and non-LT groups (P=.222). LT may have prevented further neurodevelopmental complications in children with MAC ≥300 μmol/L (P=.008) compared with non-transplant management. Therefore, Liver transplant should be considered in patients with UCD with a MAC of ≥300 μmol/L at the time of disease onset.
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Affiliation(s)
- Jun Kido
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shirou Matsumoto
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Ken Momosaki
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Rieko Sakamoto
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroshi Mitsubuchi
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Fumio Endo
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Abstract
Living-donor liver transplantation is an important component of all liver transplant programs especially in those that care for the pediatric population. Over the last 30 years, innovations in surgical technique have converted living donation from an experimental procedure to a standard of care. Many of these innovations occurred in countries where culturally, deceased donation is limited leaving no alternatives but living donation. The Organ Transplantation Center at the National Center for Child Health and Development (NCCHD) in Tokyo, Japan, was established in 2005 where we have generated some of those innovations and in so doing, have performed living-donor liver transplantation in over 400 children. Here we review the indications, technical details, and outcomes of that cohort.
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Affiliation(s)
- Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan.
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan
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12
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Factors Associated with Development of Food Allergy in Young Children after Liver Transplantation: A Retrospective Analysis of 10 Years' Experience. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1698-1706. [PMID: 28550984 DOI: 10.1016/j.jaip.2017.04.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 03/31/2017] [Accepted: 04/05/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND Although development of food allergy after liver transplantation is most commonly described in young children, little is known about identification of young liver-transplant recipients who are at risk of food allergy. OBJECTIVE This study aimed to identify the types of food allergy and the risk factors for the development of food allergy after liver transplantation. METHODS This was a retrospective analysis of pediatric liver transplant recipients in our organ transplantation center during 2005-2015. Relevant data of all patients who underwent liver transplantation were extracted from the center's database and the medical records. Differences in patients' characteristics were evaluated for associations between food allergy and potential risk factors. Logistic regression models were used to calculate adjusted odds ratios. RESULTS We obtained the data of 206 patients under 36 months of age, 42 (20.4%) of whom developed food allergy after liver transplantation. The allergy was IgE-mediated-only in 30 (71.4%) and non-IgE-mediated-only in 10 (23.8%). Multivariate analysis found eczema at liver transplantation to be a significant risk factor (adjusted odds ratio [aOR] 2.41, 95% confidence interval [CI] 1.14-4.77, P < .05). Eczema increased the risk of developing IgE-mediated food allergy after liver transplantation (aOR 3.13, 95% CI 1.41-6.93, P < .01), whereas no significant association was observed with non-IgE-mediated food allergy. CONCLUSIONS We identified eczema at liver transplantation as a significant risk factor for the development of IgE-mediated food allergy after liver transplantation, but not non-IgE-mediated food allergy. Our findings may contribute to a better understanding of the susceptible subgroup requiring special caution and to the establishment of effective strategies for prevention.
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13
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Kido J, Kawasaki T, Mitsubuchi H, Kamohara H, Ohba T, Matsumoto S, Endo F, Nakamura K. Hyperammonemia crisis following parturition in a female patient with ornithine transcarbamylase deficiency. World J Hepatol 2017; 9:343-348. [PMID: 28293384 PMCID: PMC5332424 DOI: 10.4254/wjh.v9.i6.343] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 01/02/2017] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
Ornithine transcarbamylase deficiency (OTCD) is an X-linked disorder, with an estimated prevalence of 1 per 80000 live births. Female patients with OTCD develop metabolic crises that are easily provoked by non-predictable common disorders, such as genetic (private mutations and lyonization) and external factors; however, the outcomes of these conditions may differ. We resuscitated a female patient with OTCD from hyperammonemic crisis after she gave birth. Hyperammonemia after parturition in a female patient with OTCD can be fatal, and this type of hyperammonemia persists for an extended period of time. Here, we describe the cause and treatment of hyperammonemia in a female patient with OTCD after parturition. Once hyperammonemia crisis occurs after giving birth, it is difficult to improve the metabolic state. Therefore, it is important to perform an early intervention before hyperammonemia occurs in patients with OTCD or in carriers after parturition.
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14
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Oishi K, Arnon R, Wasserstein MP, Diaz GA. Liver transplantation for pediatric inherited metabolic disorders: Considerations for indications, complications, and perioperative management. Pediatr Transplant 2016; 20:756-69. [PMID: 27329540 PMCID: PMC5142218 DOI: 10.1111/petr.12741] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2016] [Indexed: 12/13/2022]
Abstract
LT is an effective therapeutic option for a variety of IEM. This approach can significantly improve the quality of life of patients who suffer from severe disease manifestations and/or life-threatening metabolic decompensations despite medical/dietary management. Due to the significant risks for systemic complications from surgical stressors, careful perioperative management is vital. Even after LT, some disorders require long-term dietary restriction, medical management, and monitoring of metabolites. Successful liver transplant for these complex disorders can be achieved with disease- and patient-specific strategies using a multidisciplinary approach. In this article, we review indications, complications, perioperative management, and long-term follow-up recommendations for IEM that are treatable with LT.
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Affiliation(s)
- Kimihiko Oishi
- Departments of Pediatrics, Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Ronen Arnon
- Departments of Pediatrics, Pediatric Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, The Recanati / Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY10029
| | - Melissa P. Wasserstein
- Departments of Pediatrics, Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - George A. Diaz
- Departments of Pediatrics, Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029
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15
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Schielke A, Conti F, Goumard C, Perdigao F, Calmus Y, Scatton O. Liver transplantation using grafts with rare metabolic disorders. Dig Liver Dis 2015; 47:261-70. [PMID: 25498135 DOI: 10.1016/j.dld.2014.11.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 10/26/2014] [Accepted: 11/06/2014] [Indexed: 12/11/2022]
Abstract
Metabolic diseases that involve the liver represent a heterogeneous group of disorders. Apart from the metabolic defect, the subject's liver functions may be normal. With the increasing need for organs, livers from donors with metabolic diseases other than familial amyloid polyneuropathy might be possibly used for transplantation. However, whether such livers qualify as grafts and how they might impact recipient outcome are still unanswered questions. This review of the literature summarizes current experience in the use of such grafts in the context of cadaveric, domino, and living-related liver transplantation.
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Affiliation(s)
- Astrid Schielke
- AP-HP, Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital La Pitié - Salpêtrière, Paris, France.
| | - Filomena Conti
- AP-HP, Department of Hepatogastroenterology, Hôpital La Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France; Université Pierre et Marie Curie, 4 Place Jussieu, Paris, France.
| | - Claire Goumard
- AP-HP, Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital La Pitié - Salpêtrière, Paris, France.
| | - Fabiano Perdigao
- AP-HP, Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital La Pitié - Salpêtrière, Paris, France.
| | - Yvon Calmus
- AP-HP, Department of Hepatogastroenterology, Hôpital La Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France; Université Pierre et Marie Curie, 4 Place Jussieu, Paris, France.
| | - Olivier Scatton
- AP-HP, Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital La Pitié - Salpêtrière, Paris, France; Université Pierre et Marie Curie, 4 Place Jussieu, Paris, France.
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16
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Kasahara M, Sakamoto S, Horikawa R, Koji U, Mizuta K, Shinkai M, Takahito Y, Taguchi T, Inomata Y, Uemoto S, Tatsuo K, Kato S. Living donor liver transplantation for pediatric patients with metabolic disorders: the Japanese multicenter registry. Pediatr Transplant 2014; 18:6-15. [PMID: 24283623 DOI: 10.1111/petr.12196] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2013] [Indexed: 12/11/2022]
Abstract
LDLT is indicated for a variety of metabolic disorders, primarily in Asian countries due to the absolute scarcity of deceased donor LT. We analyzed data for all pediatric LDLTs performed between November 1989 and December 2010, during which 2224 pediatric patients underwent LDLT in Japan. Of these patients, 194 (8.7%) underwent LDLT for metabolic disorders. Wilson's disease (n = 59; 30.4%) was the most common indication in the patients with metabolic disorders, followed by OTCD (n = 40; 20.6%), MMA (n = 20; 10.3%), and GSD (n = 15; 7.7%). The one-, five-, 10-, and 15-yr patient and graft survival rates were 91.2%, 87.9%, 87.0%, and 79.3%, and 91.2%, 87.9%, 86.1%, and 74.4%, respectively. Wilson's disease and urea cycle deficiency were associated with better patient survival. The use of heterozygous donors demonstrated no negative impact on either the donors or recipients. With regard to X-linked OTCD, symptomatic heterozygote maternal donors should not be considered potential donor candidates. Improving the understanding of the long-term suitability of this treatment modality will require the registration and ongoing evaluation of all patients with inherited metabolic disease considered for LT.
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Affiliation(s)
- Mureo Kasahara
- National Center for Child Health and Development, Tokyo, Japan
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17
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Fagiuoli S, Daina E, D'Antiga L, Colledan M, Remuzzi G. Monogenic diseases that can be cured by liver transplantation. J Hepatol 2013; 59:595-612. [PMID: 23578885 DOI: 10.1016/j.jhep.2013.04.004] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 04/02/2013] [Accepted: 04/02/2013] [Indexed: 02/08/2023]
Abstract
While the prevalence of most diseases caused by single-gene mutations is low and defines them as rare conditions, all together, monogenic diseases account for approximately 10 in every 1000 births according to the World Health Organisation. Orthotopic liver transplantation (LT) could offer a therapeutic option in monogenic diseases in two ways: by substituting for an injured liver or by supplying a tissue that can replace a mutant protein. In this respect, LT may be regarded as the correction of a disease at the level of the dysfunctional protein. Monogenic diseases that involve the liver represent a heterogeneous group of disorders. In conditions associated with predominant liver parenchymal damage (i.e., genetic cholestatic disorders, Wilson's disease, hereditary hemochromatosis, tyrosinemia, α1 antitrypsin deficiency), hepatic complications are the major source of morbidity and LT not only replaces a dysfunctional liver but also corrects the genetic defect and effectively cures the disease. A second group includes liver-based genetic disorders characterised by an architecturally near-normal liver (urea cycle disorders, Crigler-Najjar syndrome, familial amyloid polyneuropathy, primary hyperoxaluria type 1, atypical haemolytic uremic syndrome-1). In these defects, extrahepatic complications are the main source of morbidity and mortality while liver function is relatively preserved. Combined transplantation of other organs may be required, and other surgical techniques, such as domino and auxiliary liver transplantation, have been attempted. In a third group of monogenic diseases, the underlying genetic defect is expressed at a systemic level and liver involvement is just one of the clinical manifestations. In these conditions, LT might only be partially curative since the abnormal phenotype is maintained by extrahepatic synthesis of the toxic metabolites (i.e., methylmalonic acidemia, propionic acidemia). This review focuses on principles of diagnosis, management and LT results in both paediatric and adult populations of selected liver-based monogenic diseases, which represent examples of different transplantation strategies, driven by the understanding of the expression of the underlying genetic defect.
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Affiliation(s)
- Stefano Fagiuoli
- Gastroenterology and Transplant Hepatology, Ospedale Papa Giovanni XXIII, Bergamo, Italy.
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18
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Shigeta T, Hsu HC, Enosawa S, Matsuno N, Kasahara M, Matsunari H, Umeyama K, Watanabe M, Nagashima H. Transgenic pig expressing the red fluorescent protein kusabira-orange as a novel tool for preclinical studies on hepatocyte transplantation. Transplant Proc 2013; 45:1808-10. [PMID: 23769049 DOI: 10.1016/j.transproceed.2013.01.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 01/15/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Research on hepatocyte transplantation as an alternative or supplementary treatment for liver transplantation is progressing. However, to advance to clinical trials, confidence in the technique must be established and its safety must be validated by conducting experiments using animals of comparable sizes to humans, such as pigs. We used transgenic pigs expressing red fluorescence protein for investigating the distribution and survival of transplanted cells. MATERIALS AND METHODS Donor hepatocytes were isolated from transgenic Kusabira-Orange (KO)-expressing pigs (age, 41 days; weight, 10 kg) created by in vitro fertilization using sperm from a transgenic-cloned KO pig by Matsunari et al. and ova from a domestic pig. The hepatocyte transplant recipients were the nontransgenic, KO-negative littermates. In these recipient pigs, double lumen cannulae were inserted into the supramesenteric veins to access the hepatic portal region. KO-positive donor hepatocytes from the transgenic male pig were isolated using collagenase perfusion. Hepatocytes (1 × 10(9) cells) were transplanted through the cannula. For estimating allogeneic immunogenicity, full-thickness skin (3 × 3 cm) from the same donor was grafted orthotopically on the neck region of the recipients. Immunosuppressive treatment was not implemented. The recipient pigs were humanely killed at 7 and 39 days after transplantation, and the organs were harvested, including the lungs, heart, liver, pancreas, and kidneys. RESULTS Strong red fluorescence was detected in both the parenchymal and nonparenchymal hepatocytes of the transgenic male donor pig by fluorescent microscopy. Transplanted cells were detected in the liver and lung of the recipient pigs at 7 days after perfusion. Hepatocytes remained in the liver and lung of recipients on day 39, with lower numbers than that on day 7. CONCLUSION Transgenic pigs expressing the fluorescent protein KO serve as a useful model of cell transplantation in preclinical studies.
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Affiliation(s)
- T Shigeta
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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19
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Kido J, Nakamura K, Mitsubuchi H, Ohura T, Takayanagi M, Matsuo M, Yoshino M, Shigematsu Y, Yorifuji T, Kasahara M, Horikawa R, Endo F. Long-term outcome and intervention of urea cycle disorders in Japan. J Inherit Metab Dis 2012; 35:777-85. [PMID: 22167275 DOI: 10.1007/s10545-011-9427-0] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2011] [Revised: 11/10/2011] [Accepted: 11/20/2011] [Indexed: 02/06/2023]
Abstract
Urea cycle disorders (UCDs) are one of the most frequently inherited metabolic diseases in Japan, with an estimated prevalence of 1 per 50,000 live births. Here, we investigated the clinical manifestations, treatment, and prognosis of 177 patients with UCDs who were evaluated and treated from January 1999 to March 2009. These included 77 cases of neonatal-onset UCDs and 91 cases of late-onset UCDs. The most common UCD was ornithine transcarbamylase deficiency (OTCD), which accounted for 116 out of 177 patients. This result is similar to a previous study performed between 1978 and 1995 in Japan: OTCD accounted for about two-thirds of the total number of UCD cases. We studied the relationship between prognosis and the peak blood ammonia level at the onset in 151 UCD patients. Compared with a previous survey conducted in Japan, we found that a greater number of patients survived without any mental retardation despite their peak blood ammonia levels being greater than 360 μmol/l. The 5-year survival rate of patients with OTCD improved to 86% for those with the neonatal-onset type and to 92% for those with the late-onset type. We hypothesize that the increased survival rate is due to early diagnosis and better treatments that are now available in Japan. It is very important to diagnose and treat UCDs, especially OTCD, when the blood ammonia levels in patients are low. The outcome in patients with low blood ammonia levels was better than that in patients with high blood ammonia levels.
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Affiliation(s)
- Jun Kido
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto City, Kumamoto Prefecture 860-8556, Japan
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20
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Funghini S, Thusberg J, Spada M, Gasperini S, Parini R, Ventura L, Meli C, De Cosmo L, Sibilio M, Mooney SD, Guerrini R, Donati MA, Morrone A. Carbamoyl phosphate synthetase 1 deficiency in Italy: clinical and genetic findings in a heterogeneous cohort. Gene 2011; 493:228-34. [PMID: 22173106 DOI: 10.1016/j.gene.2011.11.052] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 11/07/2011] [Accepted: 11/21/2011] [Indexed: 10/14/2022]
Abstract
Carbamoyl Phosphate Synthetase 1 deficiency (CPS1D) is a rare autosomal recessive urea cycle disorder, potentially leading to lethal hyperammonemia. Based on the age of onset, there are two distinct phenotypes: neonatal and late form. The CPS1 enzyme, located in the mitochondrial matrix of hepatocytes and epithelial cells of intestinal mucosa, is encoded by the CPS1 gene. At present more than 220 clear-cut genetic lesions leading to CPS1D have been reported. As most of them are private mutations diagnosis is complicated. Here we report an overview of the main clinical findings and biochemical and molecular data of 13 CPS1D Italian patients. In two of them, one with the neonatal form and one with the late form, cadaveric auxiliary liver transplant was performed. Mutation analysis in these patients identified 17 genetic lesions, 9 of which were new confirming their "private" nature. Seven of the newly identified mutations were missense/nonsense changes. In order to study their protein level effects, we performed an in silico analysis whose results indicate that the amino acid substitutions occur at evolutionary conserved positions and affect residues necessary for enzyme stability or function.
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Affiliation(s)
- S Funghini
- Metabolic and Muscular Unit, Clinic of Paediatric Neurology, Meyer Children's Hospital, Florence, Italy
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21
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Current world literature. Curr Opin Pediatr 2011; 23:700-7. [PMID: 22068136 DOI: 10.1097/mop.0b013e32834dda34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Bates TR, Lewis BD, Burnett JR, So K, Mitchell A, Delriviere L, Jeffrey GP. Late-onset carbamoyl phosphate synthetase 1 deficiency in an adult cured by liver transplantation. Liver Transpl 2011; 17:1481-4. [PMID: 21837743 DOI: 10.1002/lt.22407] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Urea cycle disorders (UCDs) are rare causes of hyperammonemic encephalopathy in adults. Most UCDs present in childhood and, if unrecognized, are rapidly fatal. Affected individuals who survive to adulthood may remain undiagnosed because of clinicians' unawareness of the condition or atypical presentations. We describe the case of a 49-year-old man who initially presented with a stroke and developed hyperammonemic encephalopathy over a period of 8 months. A diagnosis of carbamoyl phosphate synthetase type 1 deficiency was made, and the patient was referred for liver transplantation. One year after liver transplantation, the patient had normal plasma ammonia concentrations and had returned to work.
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Affiliation(s)
- Timothy R Bates
- Department of Internal Medicine, Swan District Hospital, Middle Swan, Western Australia, Australia.
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